Despite Medicare expenditures of $6 billion/year, mortality rates for American hemodialysis patients are the highest in the world at 23%/year. Since adequate amounts of dialysis and protein nutrition are strongly associated with improved survival, this high mortality rate may be due in part to barriers to delivery of dialysis and protein nutrition. The reasons why 20-40% of American patients receive inadequate dialysis or protein nutrition are poorly understood. Potential barriers include: ability to obtain treatment (e.g. transportation), patient noncompliance, inadequate prescription of dialysis or protein intake, medical limitations (e.g. low blood pressure), or technical limitations (e.g. clotting). However, the actual importance of these potential barriers is not known. We propose to determine which barriers actually limit the delivery of adequate dialysis and protein nutrition as well as their quality of life and resource implications. We will interview and abstract the charts of 300 patients randomly selected from all 22 dialysis units in northeast Ohio. We will use a cross sectional design to determine the barriers to adequate dialysis. We will use bivariable and multivariable analyses to examine the relationship between amount of dialysis and various predictor variables. Predictors will be patient demographic and medical characteristics as well potential barriers to adequate dialysis. A similar procedure will be used to determine the barriers to adequate protein nutrition. To determine the quality of life implications of inadequate dialysis and protein nutrition, we will examine the relationship between quality of life and amount of dialysis, amount of protein nutrition, and patient demographic and medical characteristics. To determine the resource implications of barriers, we will determine total Medicare reimbursements of all patients for a six month interval following our assessments of barriers and amount of dialysis and protein nutrition. We will then examine the relationship between reimbursements and amount of dialysis, amount of protein nutrition, and patient demographic and medical characteristics. Our study will lead to better understanding of factors that act as barriers and their quality of life and resource implications. These results will be a first step toward designing interventions to increase the delivery of adequate dialysis and protein nutrition. Such interventions may also lead to improved survival, quality of life, and resource utilization.